RENEWAL APPLICATION

Transcription

1 LOUISIANA BOARD OF EXAMINERS FOR SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY SWAMP ROAD, BUILDING 3, SUITE B PRAIRIEVILLE, LOUISIANA PHONE: (225) or (800) RENEWAL APPLICATION PROVISIONAL & RESTRICTED SPEECH-LANGUAGE PATHOLOGIST PROVISIONAL SLP ASSISTANTS & SLP ASSISTANTS Timely renewals must be submitted by June 30, Delinquent requests for renewals will be accepted through October 31, Renew online at and receive updated license card within one week. Renewals by mail may take up to six weeks for processing. Renewal Completed between April 15 and June 30, $ Renewal Completed between July 1 and July 31, $ Renewal Completed between August 1 and October 31, $ Provisional and Restricted Speech-Language Pathologists can now renew online. Supervision documents must be uploaded. Licensees who allow their license to lapse and apply to reinstate between November 1, 2016 and June 30, 2017, will be required to submit a notarized application for license, the initial license fee of $ and a delinquent renewal fee of $ in accordance with the Board s Rules, Regulations and Procedures. Inactive Status: submit renewal application, renewal fee and completion of the affidavit(s) on the continuing education report. ALL FIELDS ARE REQUIRED NAME: LICENSE #: HOME ADDRESS: HOME PHONE: CITY: PARISH: STATE: ZIP: ADDRESS: DRIVER S LICENSE NUMBER: PRIMARY EMPLOYMENT SETTING: Hospital Private Practice Rehab/Agency School University Other: Not Employed PRIMARY EMPLOYER S NAME: EMPLOYER S ADDRESS: CITY: PARISH: STATE: ZIP: OFFICE PHONE #: ( ) FAX:( ) JOB TITLE: DESCRIPTION OF EMPLOYMENT: SECONDARY EMPLOYMENT SETTING: Hospital Private Practice Rehab/Agency School University Other: No Secondary Employment Setting Name, address, and address can be requested by third parties to advertise continuing education opportunities. I allow only the following to be shared. If left unchecked, all data will be shared. Name & Address Address Opt out of data sharing

2 Since your last renewal: 1. Has any state rejected your application or revoked or suspended your professional license or certificate? 2. Has any state imposed any form of disciplinary action (revocation, suspension, reprimand, fine, etc.) on you or your professional licensure? 3. Do you have any unresolved or pending complaint(s) or disciplinary action against you or your professional licensure? YES NO YES NO YES NO 4. Have you voluntarily surrendered your professional license in any state? YES NO 5. Have you been charged or convicted of any crime or unprofessional conduct? YES NO 6. To an extent that it impairs your functioning as a speech-language pathologist, have you YES NO used or are you currently using drugs, chemical substances (including controlled Employment substances in obtained Speech-Language either with or without Pathology a valid (check prescription), all that apply): or intoxicating liquors? G Part time (<30 hrs per week) G Full time (30+ hrs per week) 7. G I Have am employed you been or treated self-employed for a drug in or LA. alcohol addiction or been a participant G I am in employed an alcohol in the YES profession out of NO LA. G I or am drug employed treatment or self-employed or rehabilitation in program SLP in which you were monitored G I am or not supervised? employed in the profession of SLP 8. To an extent that it impairs your functioning as a speech-language pathologist or audiologist, have you ever been diagnosed with a mental or emotional disease or condition? YES NO Note: If you have previously provided to the Board notarized explanation(s) of such incident(s) and no further information or change of status relative to such incident(s) is available, you do not need to replicate material previously submitted to the Board during the renewal process. Your application is NOT considered complete until all supporting documents and fees have been received by the board. Required Documents: Renewal Application - completely filled out and signed CE Report Form (supporting docs only if audited) Supervision Forms (including supervision agreement) Applicable fee Renewal applications submitted via fax or are unacceptable and will be subject to late penalties. All applicants for licensure have an obligation to update and supplement the information and responses on this application if they change. Failure to supplement the information and responses on this application may result in denial or Payments may be made via check or credit card. An additional $3.00 processing fee will be added to the charge amount. Name on Card: Card Number: Expiration Date: 3-digit Security Code: I hereby request that my license to practice in Louisiana be renewed. I affirm that all information provided is true and correct. If you are unable to affirm this statement, you must attach a notarized explanation. Signature: Date:

3 Applicant s Name: CONTINUING EDUCATION REPORT 2016 Please record your continuing education activities completed during the license period July 1, 2015 through June 30, 2016, in the appropriate categories on the form provided, and submit with your license renewal for license year Each licensee shall complete continuing education activities of at least ten (10) clock hours each license period, July 1 through June 30. Of the ten (10) hours, five (5) shall be in the area of licensure, and five (5) may be in areas related to the professions of audiology and speech-language pathology. Audiologists who register as dispensing audiologists shall have at least three (3) hours of the total ten (10) hours in areas directly related to hearing aid dispensing. Dual licensees shall complete fifteen (15) hours per year with a minimum of five (5) hours in speech-language pathology and five (5) hours in audiology. LBESPA MAY REQUEST, THROUGH OFFICIAL AUDIT, VERIFICATION OF CLOCK HOURS SUBMITTED, INCLUDING INFORMATION REGARDING CONTENT, CERTIFICATION, AND ATTENDANCE. YOU SHOULD KEEP PROPER DOCUMENTATION IN THE EVENT YOU ARE AUDITED. List the date and number of hours spent in the following activities. Where required, list title of program/article. Please check whether the activity is in the area of licensure or a related area. Activity #Hours Date Area of Related Mo/Day/Yr Licensure Area 1. LBESPA-sponsored activities: 2. Meetings/conferences of speech-language hearing organizations or workshops in the area of communication disorders sponsored by individual professional practitioners or professional organizations such as ASHA, LSHA, or SPALS: 3. Activities provided by ASHA-approved continuing education providers or AAA-approved continuing education activities: 4. Meetings of related professional organizations (e.g. Council for Exceptional Children, Orton Dyslexia Society):

4 Activity #Hours Date Area of Related Mo/Day/Yr Licensure Area 5. College courses in area of licensure (3 semester hours. or 6 quarter hours. = 10 hours of CE): 6. Distance learning (video conferences, telephone seminars & Internet courses sponsored by individual private practitioners, universities, schools, clinics, state agencies, hospitals, professional organizations, or related professional organizations): 7. Workshops and in-services that are university, school, clinic, hospital or state agency sponsored (max of 5 hrs. in a related area) unlimited hrs. In area of licensure: 8. Publication of articles in a peer-reviewed journal for the year which it was published: 9. Audio, video and other media that are ASHA-approved and AAA- approved continuing education media (max of 5 hours) 11. The presenting licensee may count 1 1/2 times the value of a workshop the first time it is presented to allow for preparation time (e.g. 3 hour workshop = 4 ½ hours). The activity will count for the actual hour value for each subsequent presentation of the same activity. The following ACTIVITIES REQUIRE PRE-APPROVAL by LBESPA LBESPA requires pre-approval of self-study activities. Activity #Hours Date Area of Related Mo/Day/Yr Licensure Area 12. Audio tape(s), video tape(s) or DVDs not ASHA or AAA approved (max. 5 hours): 13. Reading of journal articles that contain self-examination questions at the end (max. 5 hours):

5 Activity #Hours Date Area of Related Mo/Day/Yr Licensure Area 14. Publication of diagnostic and/or therapeutic materials (max. 5 hours): 15. Self Study or Other pre-approved activities completed: TOTALS Number of hours in area of licensure..... Number of hours in related area.... Number of hours in areas directly related to hearing aid dispensing (if applicable) TOTAL NUMBER OF CONTINUING EDUCATION HOURS SUBMITTED... ALL APPLICANTS MUST COMPLETE THE FOLLOWING I certify that the information provided above is accurate and I can provide documentation of these activities if requested. I understand that falsification of this document can result in disciplinary action with regard to my ability to practice my profession. Signature (required) Address City, State, Zip Print or type your name Date Form Completed License Number * * * * * * * Please note that LBESPA will allow continuing education hours collected in June to count backward or forward, i.e., the 2015/2016 collection period or the 2016/2017 collection period. Hours accrued during June may be used for only one collection period and may not be divided and applied to both collection periods. There shall be no carry-over of continuing education hours in any other month from one license year to the next. * * * * * * *

6 Applicant s Name: If you hold a license but did not work in the profession of Speech-Language Pathology and/or Audiology, you are required to complete the Inactive Status Affidavit below at the time of license renewal attesting that you did not work in the profession during the license period, July 1 through June 30. Inactive Status Affidavit I,, did not practice the profession of speechlanguage pathology and/or audiology from July 1, 2015 through June 30, I understand that I must complete the continuing education requirements as stated in Rule No. 121.F. of the Board s Rules, Regulations and Procedures. Applicant Signature Date *Notarization not required for this purpose* If you hold a license that requires supervision but did not work in the profession of Speech- Language Pathology, you are required to submit a notarized statement at the time of license renewal attesting that you did not work in the profession during the license period. Affidavit in Lieu of Supervision I,, hold a license that requires SUPERVISION, but did not practice the profession of speech-language pathology from July 1, 2015 through June 30, I understand that I must complete the continuing education requirements as stated in Rule No. 121.F. of the Board s Rules, Regulations and Procedures. I certify to the Louisiana Board of Examiners for Speech-Language Pathology and Audiology that the above statement is true and correct. Applicant Signature Date Notary ID# Date *Notarization Required* Mail signed Renewal Application, Fee, Continuing Education Report and supervision forms (if applicable) to: LBESPA Highland Road, Suite B Baton Rouge, Louisiana Telephone: or Website: **PLEASE ALLOW SIX (6) WEEKS FOR THE PROCESSING OF YOUR LICENSE RENEWAL**

7 SUPERVISION FORM 200 FOR THE SPEECH-LANGUAGE PATHOLOGY ASSISTANT AND PROVISIONAL SPEECH-LANGUAGE PATHOLOGY ASSISTANT LICENSE Licensee s Name: Are you employed in more than one work setting? If so, supervision must occur in every work setting and a separate form must be submitted for each work setting. Page 1 of 2 Month Year Setting in which the supervision occurred (e.g. school, rehab, etc.): Use this form to document your monthly supervision. List the number of hours you are supervised on the appropriate dates: Articulation Therapy Language Therapy Other Therapy Speech/Language Screening Hearing Screening Articulation Assessment Language Assessment Other Assessment Parent/Family/Teacher Conf. On-Site, In-View Supervision TOTAL TOTAL Alternative Methods of Supervision Review of client folders Telephone Conference Record-keeping In-service Training Review of tapes relevant to SLP Staffing Check maintenance of equipment Scheduling/Planning Consultation TOTAL Please shade boxes for weekends. Write in holidays, illness, professional improvement days, etc. OVER

8 SAVE THIS FORM This Form is to be completed and mailed to the Board by June 30 of each year. SUPERVISION FORM FOR SPEECH-LANGUAGE PATHOLOGY ASSISTANT LICENSE AND PROVISIONAL SPEECH-LANGUAGE PATHOLOGY ASSISTANT LICENSE FORM 200 Use this form to document your monthly supervision. (Make extra copies for later use.) Page 2 of 2 Month Year At the time of license renewal, Speech-Language Pathology Assistants and Provisional Speech-Language Pathology Assistants MUST submit a Supervision Form 200 for each month of employment. Check applicable boxes: Full time 9 month employee Part time 12 month employee We hereby certify to the Louisiana Board of Examiners for Speech-Language Pathology and Audiology that the supervision information submitted on this Supervision Form 200 is true and correct. Supervisor Signature Supervisee Signature Supervisor s Printed Name Supervisee s Printed Name Supervisor s Address Supervisee s Address Supervisor s Address Supervisee s Address Supervisor s License Number Supervisee s License Number Only those hours that are directly supervised on-site, in-view may be used to fulfill the on-the-job training requirement. At the time of licensure renewal, Speech-Language Pathology Assistants and Provisional Speech-Language Pathology Assistants must submit a form 200 for each month of employment. Upon completion of the 225 practicum hours, Provisional Speech-Language Pathology Assistants must submit a written request to upgrade their license to a Speech-Language Pathology Assistant License. The written request must be submitted with the Upgrade Fee of $30.00 to the Board office at Highland Road, Suite B, Baton Rouge, Louisiana This form may be retrieved from our website at 2/08 Form 200